Stop Bullying at Irving Elementary School
This form is anonymous.

This anonymous results will be sent to Jami Turk, Irving Elementary School Assistant Principal.

Each question is optional, but please enter as much information as possible to aid us in investigating and remedying any and all bullying matters.

1. Do you feel your life is in danger?
2. Has the bullying incident/incidents been reported to a school official?
3. Who is bullying you?
Your answer
4. During the last week, how many times, if any, has someone made fun of you, called you names, or insulted you?
Your answer
5. During the last week, how many times, if any, has someone spread rumors about you?
Your answer
6. During the last week, how many times, if any, has someone pushed you, shoved you, tripped you, or spit on you?
Your answer
7. During the last week, how many times, if any, has someone threatened you with harm?
Your answer
8. During the last week, how many times, if any, has someone tried to make you do things you did not want to do; for example, give them money or other things?
Your answer
9. During the last week, how many times, if any, has someone destroyed your property on purpose?
Your answer
10. During the last week, how many times, if any, has someone left you out of or wouldn't let you join in activities on purpose?
Your answer
11. During the last week, how many times, if any, has someone used cell phones or the Internet to say or post hurtful things about you?
Your answer
12. Please add any other comments or statements below.
Your answer
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